Doris Days

Wow, the weeks seem to go by more and more quickly.  And my blogging seems to get less frequent.

We successfully completed the neonatal resuscitation course, and trained 11 midwives - one suffered a bereavement mid-course and didn't complete - despite one of the instructors getting malaria.  It was generally well received, although there were complaints about the food.  People complain about the same things, wherever you are in the world.  The three day format worked very well, although for subsequent courses we plan to run it for 2 days to keep the group sizes down.

The SHOs had exams for 2 weeks, so I covered the labour ward.  The first week there was me, one specialist and 1 to 2 interns.  Despite being extremely short staffed we managed pretty well I think.  I spent the Monday and Tuesday on the shop floor, while the specialist was in theatre with the intern.  I sutured cervical tears using the light from my mobile phone, kneeling on the floor.  I did some manual removals under pethidine sedation.  I ran around struggling to get blood, and then having to decide which of the three moribund patients - one massive APH with a live baby, one massive PPH and one severe malaria in pregnancy - who were O +ve to give the single unit I could get hold of, to.  We gave it to the woman with the APH.  All three women and the baby survived, fortunately.  I also resuscitated babies, dealt with complications of HIV, severe malaria in pregnancy and severe PET.  

I spent 3 days in theatre, battling with the usual frustrations - no catheters, no cannulae, no gloves - the patients had to bring their own, which created its own set of disasters, since it seemed to be those most in need of an urgent section that didn't have money to buy the consumables we were lacking in or didn't have attendants to go to the pharmacy and buy them.  We had  a retained twin, delivered by CS, the mother had delivered twin 1 at 1am and rocked up to Mulago at 3pm, from less than a mile away.  Baby was fortunately OK.  My section mix consisted of 1 woman with 5 previous scars in labour, 4 genuinely obstructed labours - one of whom I had to deliver by the breech - an impending rupture, a cord presentation, 4 other women with previous scars, 1 HIV +ve woman with PROM, a PG with contracted pelvis and one severe PET.  Numbers wise it wasn't a huge amount of work, but when the list often doesn't start until at least 11am - sometimes later - and with all the other rate limiting factors, on a good day in one theatre most people don't get more than 7 sections done between 9 and 5.  I had the weekend off, which cover had been arranged for, and gathered my thoughts, relaxing in the garden with a good book and plenty of coffee.

The second week the staffing numbers were a little better, 3 SHOs - including me - and two interns. This meant that we were able to run 2 theatres.  We still had issues with gloves.  We had the added problem of the student anaesthetic officers being examined on the emergency list.  This meant that the choice of anaesthetic was dictated by what they needed to be examined on rather than the clinical indication for caesarean.  It also meant that the list shifted very slowly indeed.  I spent 2 days on the labour ward shopfloor, the highlight of which was an undiagnosed multiple pregnancy, twin 1 breech, twin 2 cephalic.  I was called to assist as the arm was not deliverable on twin 1 on account of it being extended above and behind the head.  After a lot of manouvreing, I managed to hook the arm down and deliver the baby, resuscitated it, only to find that twin 2 was a compound presentation.  I managed to push the hand back, rupture the membranes and she delivered vaginally, so all was well that ended well.  

I had a challenging few days in theatre.  The first day we had 3 sections for fetal distress, a transverse lie, back down, with a previous scar and oligohydramnios at 32 weeks, who I had to do an inverted T incision on, a badly obstructed labour and 2 women with 2 previous scars.  Aside from the glove issue, the list ran fairly smoothly.  The second day, I walked into labour ward, past the admission room and spotted a woman with 2 previous scars, behaving like she had an impending rupture.  We managed to prioritise her to go in first but the anaesthetic students refused to start the list as they were waiting for their examiner to arrive.  I ended up getting annoyed, since I had expressed my concern about the likelihood of this woman rupturing.  They brought her through, and put her on the table to start the spinal, and I knew from the change in her behaviour that the uterus had ruptured.  Fortunately the baby was still alive, and although the uterus had ruptured posteriorly,  managed to repair it.  She had a PPH and required blood but subsequently did OK.  

The next patient that came in was transferred from another unit, severely anaemic, having been delivered by section the day before in another unit. I was dealing with the PPH on the corridor, so one of the other SHOs went in to start the laparotomy, finding that the bladder had been sutured to the upper lip of the uterine incision, and she had bled from the lower lip and into the broad ligament.  Again, there was no need to do a hysterectomy.  Unfortunately, because of this referral taking priority over other cases, the next woman with a severely obstructed labour ruptured anteriorly, and the baby was stillborn.  I managed again, to repair the uterus and she did OK.  We then managed to get through two more sections - 2 and 3 previous scars in labour - before finishing for the day and handing over to the night team.

The next morning I walked into theatre to an almost identical scenario - students awaiting examiners, another impending rupture - who again, ruptured on the table, with a live baby.  Unfortunately the rupture also involved the bladder and I couldn't confidently find the apex or the ureters, so I called the specialist in.  That day we also had 2 undiagnosed praevias, a breech with a cord prolapse, one CPD and a severe PET.  It was nice to hand the house over on the last evening, knowing that I wouldn't be taking it back again the next morning.

The next week was dedicated to finalising some stuff for the upcoming Liverpool Mulago exchange, putting the finishing touches to the HDU paintwork and completing some of the paperwork that we need in order to get the HDU running.

Being so busy at work meant that I wasn't at home very often, and had particularly missed relaxing in my own space, and also spending time with my housemates.  Doris, our housekeeper has been a constant source of interesting conversation recently.  She's a formidable woman with a hatred of men - for reasons we are not sure of - and is inherently suspicious when new people, particularly of male gender, move into the house.  She collared me in the living room when I got home while she was still at the house...

Doris; 'Who has been feeding the bones of fish to her?'

Me; 'Who has been feeding the bones of fish to who?'

Doris; 'Someone has been feeding the bones of fish to Pasha'

Pasha is a male dog.  Doris is forever confusing gender, and will refer to Adam, Pasha, Justus and George as she or her, while referring to me and Elizabeth as he or him.

Me; 'I don't know who has been feeding fish bones to Pasha'

Doris (accusingly); 'It must have been Justins [Justus] or George.'

Me; 'I doubt it was Justus, it may have been George'

Doris; 'You need to speak to her, in my country when they are trying to kill a dog, they feed her the bones of fish'

Or another conversation a matter of days later

Doris; 'She has been stealing plates and bowls and knives and forks'

Me; 'Who has been stealing?'

Doris; 'Justins [Justus].  And she stole my pegs'

When Doris settles her mind on something, it can be impossible to change it.  We have a new housemate, Chi, a Tropical Medicine SpR from London. 

Chi; 'Hi Doris, my name's Chi'

Doris; 'Cheese?'

Chi; 'No, C-H-I. Chi.'

Doris; 'Yes, Cheese.  Welcome'

Doris recently found 70,000USh in my trouser pockets, which I'd abandoned in the washing basket.  She is a woman of the utmost honesty and integrity.  Having discovered the money she spoke to Adam who was the only one home...

Doris; 'Whose are these trousers?'

Adam; 'I don't know'

Doris; 'I think they are for Kate sometimes'

Adam; 'I don't know Doris'

Doris; 'Yes, they belong to Kate sometimes.' (Long pause, Adam looks around room uncomfortably) 'I found this money in them'.

I don't know who my trousers belong to the rest of the time, if they're only mine sometimes, but hey ho.  I admire Doris.  She grafts to school her kids, as a single mother, strong, stubborn and doesn't take any sh*t from anyone.  I will miss her when it is finally time to leave.

A Chimp Off the Old Block

Things have really picked up pace.  With only 11 weeks left here I have so much to complete.  I'm in that pre-amble phase of writing lots of lists and making pretty coloured timelines, which is somehow reminiscent of revising for any set of important exams.  'We need the induction of labour guideline urgently' and 'When can you set up the HDU?  This weekend?' suggested to me that the head of department is also conscious of my nearing departure.

Induction of labour is at best haphazard here.  We had a case of uterine rupture in a woman, who had an induction which had been carried out in line with FIGO recommendations, that made the department collectively twitchy about the induction process.  There are no true written rules, and while everyone sort of does the same thing, it's not uncommon to come across women who seem to be undergoing an eternal induction.  So rapid action was required and Prof Lule was quick out of the starting blocks to get something put together on induction , while I worked to pull together the evidence for use of Misoprostol throughout obstetrics and gynaecology, and summarise it in a presentation.  We presented both pieces of work together in the morning meeting and there was a lot of debate and discussion about exactly what we should do here to induce labour.  Different people have different opinions about what works, based on personal experience.  The difficulty is consolidating that with what is in the literature and what is deemed to be safe.  I think this will be one of the most difficult guidelines to ratify here - there are a lot of strong-willed people with differing opinions.

Big things have happened with HDU.  I've mentioned it previously here, but there's a definite need for some sort of high dependency care.  I have felt strongly about this since arriving at Mulago, having discussed it with my predecessor, and the idea gathered momentum after Mark Muyingo went to Liverpool and identified a need for a high dependency area for postnatal women.  We unsuccessfully bid for funding to set it up, learning we had not won the money in early February.  The idea for a 'shoestring' HDU has been floated around and I finished the first draft of the concept paper.  The Friday before last the Head of Department, the Ugandan LMP team and I went to ward 5C and identified the latent phase room as the best place to put it. 'When can you start work?  This weekend', was no joke, although it was too short notice to co-ordinate painting.  'Next weekend' was my reply.

Working on guidelines has allowed me to eat lunch away from the hospital with my housemates.  I was sitting waiting for Adam, Avner and Phoebe to join me one afternoon.  Adam came bouncing into the restaurant, clearly quite wound up.  He had had an altercation with a taxi conductor over 400 shillings (about 12p), in which the conductor had snatched a packet of photos from Phoebe's hand as a way of forcing them to pay more than the usual fare because they were Mzungu.  It seemed to get out of hand, and culminated in Adam slapping him, grabbing the photos back and running away.  There's a degree of racism here, when it comes to paying for stuff, and the 'Mzungu price' often gets hiked way above the local cost.  This gets very wearing at times, when you live here and you know what goods and services are supposed to cost.  I guess Adam had reached the end of his tether.  Time to leave the country - he's currently chilling in Zanzibar.

I joined my housemate Avner for a march on labour day (May 1st).  We were marching against child labour.  I was under the impression that this would be a huge organised thing.  We turned up at the roundabout by the Northern bypass at 8.15 ready to march en masse.  The few of us in our group were the only people there apart from a group of security guards.  It turned out that the march had been cancelled, but that not everyone had been informed.  All the other groups were already at the shcool where the march was supposed to conclude.  So we walked for 5 km to get the, in the beating sun, to find that in fact, the majority of people that were there were from large corporate firms, present to keep the politicians happy.  The only other group that was even vaguely similar to us was the Ugandan Nurses Union.  So there was I, ready to chant and burn stuff in protest, only to find that I had to plod round the parade ground in front of the powers that be, and be on my best behaviour in front of the mayor and various other invited guests.  We were on TV that evening, but I don't think we got our message across! 

Phoebe and Mark left to go back home to Canada last week.  Our small group of close friends is ever decreasing in size.  We had a lot of fun with them, but apparently Sescatchewan was calling them.  Great opportunity for a Canadian break though!

On a different note, I have a regular boda boda driver who brings me to work in the morning.  Alan is dependable, obliging and above all, a safe driver.  We don't talk about much, but I like him.  He had come to the house one afternoon, with a problem.  Driving a boda boda is a way of making ends meet.  Most of these guys don't own their bikes, but rent them from shrewd characters who know how to snare people into a rental agreement that is difficult to break away from due to financial constraints.  On average, Alan earns 80k per week (about £25).  He rents his bike for 50k a week, and puts around 20k worth of fuel in on top of this.  He therefore has a take home of 10k per week, and this has to pay his rent and feed his wife and 3 kids.  He has rented his bike for 18 month, having previously worked in a photography studio.  He gave this job up because he wasn't paid for 4 months and driving a boda boda was the only option available to him.  The guy he rents the bike from announced that he had sold the bike, and had bought a matatu, and that the bike would no longer be available to rent, but he could buy it for 1.8 million shillings.  Alan's livelihood was at risk, and he was asking us to help him out with a loan.  None of us had the capital sitting round to do this.  I went to the bank with Alan, but the loan situation was impossible, and microfinance companies wouldn't make a loan big enough to cover the cost of a bike.  Alan had decided that rental was a mugs game and that buying a bike was a way of sealing a future, with his goal of being able to buy land to farm and to school his kids.  I really wanted to help him out.  Then my housemate Avner mentioned a hire purchase scheme set up by an American journalist.  The boda driver gets a brand new bike, he pays back over a period of 17 months with interest, but the papers are in his name and he walks away at the end of it with a good bike and 50k extra a week in his back pocket.  I made some calls, arranged for Alan to meet the scheme manager and I put the deposit up for him, which he'll pay me back by bringing me to work for free.  He turned up at the house with his brand new bike, beaming, ready to start a new chapter in his life, that will enable him to make a better future for him and his family.

Louise Ackers and Carol Porter arrived from Liverpool last week to present the findings of the evaluation they have done on the Liverpool Mulago Partnership.  They have done some awesome work looking at patterns and trends in morbidity and mortality, including some really interesting work mapping out where the women that die at Mulago come from.  This will perhaps allow us to address some of the logistical issues that contribute to maternal mortality here, such as transportation, referrals, functionality of referring hospitals and clinics and so forth.  There is more data to collect and add to what has been done so far, but it's incredible to see everything collated and analysed in one place.  I'm excited to read the final version.  We attended a grant proposal writing workshop together with Judith Ajeani, one of the specialists here, for another funding bid to help in setting up the HDU, but more importantly to evaluate the impact that it has on care here.  If we can get this funding, it will be a huge milestone for the partnership, and will strengthen the links that the team have worked so hard to forge.  It will allow us to see whether what is actually a relatively simple intervention does make a difference in this environment.  I'm keeping my fingers very tightly crossed.  It was great to spend time working with them.  I met a Liverpool palliative care consultant at the workshop, Dr Merriman, who had been a care of the elderly consultant at Whiston Hospital back in the day, and who set up Hospice Africa.  It's a frighteningly small world.  

We have finally unravelled what was happening with the maternal death audit data, which we need as a detailed baseline from which to measure the impact that various initiatives are having here.  The data has simply disappeared.  So I have 184 files to audit from 2009. They also brought a heap of donated equipment for the department.  We had a nice meal with the Ugandan members of the exchange on the Friday evening.

On Saturday we travelled to Ngamba Island chimpanzee sanctuary.  I had forgotten how rough Lake Victoria gets, and by the time we had made the 45 minute speedboat crossing in the lashing rain we were soaked to the skin.  We spent a happy hour watching the chimps at play, socialising, chasing each other and interacting.  We share 98.7% of a chimpanzee's DNA.  The resemblance is scary.  The chimps are all orphaned or rescued from injury, or from being kept as pets.  We got back slightly less damp than we arrived.

On Sunday we deep cleaned the HDU and painted it.  7 of us - me, Louise, Carol, Mark Muyingo from Mulago, and my housemates Av, Eric and Carine - set to it with wire scourers and brushes, tackling all the surfaces and washing off years of grime.  We the covered the room in soft white, managing to get three coats on before we ran out of energy.  We need to go back and put the finishing touches to it, but it does actually look like we mean business.  Once the painting's finished, we'll get mosquito grilles up and start to put the equipment in.

Andrew Weeks arrived on Monday morning, so we had a few drinks and dinner on Monday night.  We'll spend a bit of time working on the HDU proposal while he's here.  Carol and Louise left on Monday afternoon.  The rest of the week will be spent training the midwives in neonatal resuscitation.  We have 12 candidates this time, due to problems with staffing and rotas.  The good news is that I have enough money to run a further three 3 day courses in July.  It will be my swansong before heading back to Blighty.

Photos of the HDU so far are here and chimps are here

Chicken Run

We travelled to Arua the day before the outreach camp was due to start. Arua is in the far north west corner of Uganda, near the border with the DRC and Sudan. We knew we had a long day ahead of us, and so we set off at 9.25am - not bad considering we planned to leave at 9. Armed with the Sunday papers, myself, Barageine, Alia and Rose set off with our driver in a Landcruiser. Once we escaped the clutches of the jam - even on a Sunday morning - we made a fairly good pace. We stopped along the road to buy skewers of beef muchomo, barbecued plantain and maize from the throng of vendors at the turn off for Masindi. Not a bad breakfast, and much cheaper than chips! We continued along the road, skirting along the edges of Murchison Falls National Park. We spotted baboons patrolling the roadside, donating the remains of breakfast - at high speed I might add - to them. We crossed the Nile - awesome as always - and carried on west through Pakwach and beyond.

Not far out of Pakwach, the car suddenly veered to the right side of the road, into the path of an oncoming bus, which was screaming down the road like something possessed. The driver managed to get the car back across to the other side of the road before we were hit, but it was a little hairy. We came to a halt, and got out to check the cause of the problem... a punctured back tyre. Which would have been fine, except that the jack for the car wasn't big enough, and while we could get the wheel off, we couldn't get the spare on. And so ensued the search for a flat rock, to place under the jack, and a series of improvisational measures were employed to keep the car elevated enough for us to take the jack out from under it, and place a sturdy and big enough rock under the jack, so that we could lift the car high enough to get the wheel on, in the baking heat, with no drinking water between us, on a deserted road, in lion country. We succeeded in completing the task at hand, and piled back in the car, a tad sweatier and dustier than we'd been when we got out.

We stopped in Nebbi to visit Rose's family and to drop off some bread which we had bought in Kampala - bread's very expensive in the north, so it's a rare treat shortly before stopping for lunch, which after the tyre fiasco was welcome. We travelled for around another hour, passing IDP camps made up of round huts of mud and straw. Some of the buildings were pockmarked with bulletholes - evidence of the still relatively recent struggle with the LRA. We hit Arua, a big, bustling market town, full of pedestrians and cyclists. We checked into the Hotel Pacific - which, in a landlocked country is surprisingly nowhere near the pacific, nor did it seem to have any features to suggest a tie with the pacific ocean. Either way if was fine, comfortable enough, apart from the howling scrapping dogs in the alley behind the rooms and the roosters that crowed incessantly from 4am, in a manner suggesting that they were being skinned alive. We settled down in the hotel for a beer or 2, and had a bite to eat.

Alia wanted to go to his Dad's village to pick up some chicken that had been killed and cooked for us, but there was an issue with taking the Landcruiser. The chicken arrived, by boda boda, with a pan of matoke and some sugar cane, right after we had finished eating dinner, so we loosened our belts and tucked in.

Next morning, we got to the hospital. The patients had been screened by Alia and Barageine shortly after we arrived in town. We got to theatre around 9, and I was pleasantly surprised by the theatre, which was a far, far cry from Mityana's. The first patient was waiting, drip in hand. The day got off to a flying start. The staff were motivated, and apart from the anaesthetist who repeated the phrase, 'That's next to impossible' regarding our request for a fan to help survive the heat were very positive. We got our fan - which was just as well, or else I'd have melted. We got through all 5 scheduled patients by 4pm and screened the new arrivals. We headed off for a well earned drink - which swiftly turned into 6, plus fish and chips, Alia insistent on 'just one more beer' for all of us - makes a change from me saying it anyway!

This camp turned out to be the best so far, everything ran like clockwork, we had good light, running water, instruments and proper linen, a motivated team, the hospital's own doctors got involved and there were even medical students around! The fistulas were among some of the most complicated I've seen so far, which was interesting to see. In the end, however, we only operated on 13 women. This was a question of people not coming to the camp to be treated - everyone we saw that needed surgery got it. We left Arua on the Wednesday afternoon. Prior to leaving, Alia went off to collect a chicken from the village, which was bundled into the car, clucking manically.

We hit the road on what was to be a long drive. We stopped not too far outside of Arua to buy Mangoes from kids on the roadside, prompting stories from the guys about how they used to scrump for mangoes. They had kids running up and down the road buying plastic bags. Fruit purchased, we continued on our journey. We stopped at Rose's village to collect another Chicken to keep the one we already had company, which doubled the noise asince they decided to peck at each other. Loading the car up with more mangoes we set off again. In Pakwach, we stopped again, this time to invest in wooden milking stools with phrases etched into them. My particular favourite was 'Remember Pakwach'. What?! After politely explaining to the 20 people flocking around the 4x4 that I didn't need any wooden crocodiles, cars, crested cranes, innominate birds, balancing objects, bows and arrows or drums, and everyone else satisfied with their purchases we drove across the Nile. On the other side were tens and tens of Elephants. Alia hypothesised that they were all going down to the river to drink. Barageine disagreed, stating that they had almost certainly already drunk from the river and were heading in the opposite direction. Rose and I looked at each other and burst out laughing, suggesting that since they were all facing in different directions it was difficult to tell what they were doing or where they were going, and either of them could be right, but that they were arguing for the sake of it. After an hour we stopped again. Alia bought 4 more chickens and Barageine bought 6, bringing the total to 12, making for a bloody noisy car, and reminding me why sometimes having no sense of smell has its advantages. The rest of the journey was relatively uneventful, apart from a heavy downpour. Getting the chickens out at the other end proved to be a challenge and I finally got through the front door at 10.30.

Since arriving back from Arua, I've spent a lot of time doing project work. I've spent time preparing and co-ordinating stuff for the next exchange visitors from Liverpool Women's - registration, accommodation etc - and also trying to sort out visas for the Ugandans who are hoping to visit LWH. I've been working on a detailed proposal for a shoestring HDU, and have made the final arrangements for a neonatal resuscitation course. Many of you have donated generously, and so far I've collected almost £1000 in donations - THANK YOU! We're also hoping to present on a few new guidelines for the unit next week and so have been putting the finishing touches to these. From here until I leave things are going to be fairly intense, with 3 separate groups of visitors coming who are working on fairly different things, we'll be physically setting up the HDU at some point in the next 6 weeks and there are post-graduate exams, so I'll cover labour ward for 2 solid weeks.

Thursday was pub quiz, the first one we've been to in a while. We had some new additions to the team, Anna, a medical student, and Whiteney and Lisa, 2 nursing students, plus Phoebe and Mark joined us for the first time. We came 2nd. Slowly we're improving - perhaps next time we might win. From here we visited Elizabeth, who has just taken a job in Rwanda - we had left her earlier in a packing frenzy - to sit and drink wine on the porch one last time before she left yesterday.

Yesterday was also Adam's birthday. Phoebe and I went to pick up his birthday cake. I had explained the order, with the appropriate illustration to the lady at New York Kitchen. Rather than a whole cake, I asked if it was possible for them to give me half a chocolate cake and half a carrot cake but to put them in the same box. At some point between me explaining what we wanted and the cake arriving in the shop, somebody interpreted the order as, chocolate cake on the bottom, carrot cake on top with a layer of chocolate fondant between them, iced entirely in chocolate. What part of that combination would be normal in anyone's frame of reference.? So I waited for 25 minutes while they deconstructed the cake - since we needed it within the hour , and there wasn't time to start again from scratch - stripped off the icing, re-iced the chocolate cake and put the carrot cake in a separate box. Armed with our 2 cakes, party hat and candles, we jumped in Alfred's car. And sat in the jam. For 2 hours. School's out. We had forgotten. We got to the Italian Restaurant later than expected but had a lovely evening, and the cake, in the end, was delicious.

This weekend is my last free weekend for some time. I intend to do absolutely nothing.

It's Chilling in Kigali...

Returning from fistula camp, I had a mountain of stuff to catch up on. Many of the staff commented on my being 'lost' - read, not around - some thinking that I had abandoned Mulago forever. Not so. I did spend much of the week trying to pin people down to make progress on various things - arranging for the next wave of exchanges, getting protocols moving again and trying to work out how to take the HDU project forward without any formal funding. I managed to meet with the head of department to discuss these and more and feel that we've taken a big step closer to realising some of our ideas. We have enough basic equipment to set up an HDU if we can acquire the physical space and I'll drag my trusty band of painters back to the hospital - possibly kicking and screaming - to spruce it up. We're hoping to acquire a six bedded bay with dedicated staff. I feel perhaps that I spend a lot of time expressing 'hope' on this blog. Speaking of which, we're going to give triage another bash, this time I have permission to get the whole department involved, mobilise the doctors as well as the midwives, who we had focused all of our efforts on the last time we piloted. I'm still hopeful that we can get it working. See, there it is again... hope.

I did a bit of teaching, more interactive which seemed to be well received, and some practical refresher training on vaginal breech delivery and neonatal resuscitation. We definitely need to run another formal course. We have identified over 30 midwives who need to be retrained or trained. Initially we were looking to run a series of one day courses, but having met with Agnes, one of our in-house trainers and talked a bit more, she feels that we should run a more intensive 3 day course so that we can really drive the message about resuscitation home. I've set up a charitable donation page here, and if you're feeling generous, money is accepted in all forms... I'll even take beans if you've got 'em. We're going to do it during the first week of May. Although I didn't do any clinical work, I did achieve a lot in terms of igniting or re-igniting project work that had gone off the boil a bit.

For Easter, the three amigos - Adam, Elizabeth and myself - decided to take a road trip down to Rwanda and back to Kampala via Lake Bunyonyi. We arranged a driver for the weekend, and asked for a 4x4 vehicle. Alfred rocked up the night before departure with what looked like a clapped out Matatu (minibus taxi) and a grin on his face. Fortunately it was fairly plush inside, and since it was the 11th hour and we had no choice paid the deposit. The next morning, bleary eyed at 5.30am Alfred turns up with Dan, and the bombshell that Alfred is in fact not going to be driving us after all. Thanks for the notice, mate. We piled in, and Elizabeth and Adam were asleep before we'd even reached the outskirts of Kampala. Given that I cannot sleep in a moving vehicle of any description I was glad I had brought a stack of books with me and began to devour the first with absolute delight - I don't get to be much of a bookworm these days. We stopped on the Equator for the compulsory naff photo, a coffee and the biggest muffin in the world before continuing through Mbarara - where Dan, not being one to leave things til the last minute, had to stop to buy insurance. We ploughed on to Kabale - Uganda's highest town - where we stopped for lunch. We were pleasantly surprised when the food that we had ordered from the fairly dubious looking menu arrived, and particularly impressed by the avocado and banana milkshake. We ate our fill - eyes bigger than bellies - and proceeded to tackle the border.

I hate crossing borders by land. The process is always ludicrously bureaucratic and a total waste of ink. The Uganda-Rwanda border was no exception. The concept of queuing was non-existent and it was pouring down. Despite the seemingly tight control I am fairly certain that you could easily pass freely from one country to the other without anyone noticing - as one crazy gentleman appeared to be able to do, while muttering to himself and flailing his arms in the air. Having added a new stamp to my East African collection at the much more organised Rwandan side of the border, I got back in the car along with the others and we set off once more. There was a minor moment of panic, when Dan decided after driving for about 70 km that he should probably stop and ask someone if we were heading in the right direction, since I, who had never set foot in the country before, didn't know. We were heading in the right direction, thankfully, and I managed to stop myself from suggesting to the driver that following a random truck from the border in the hope that it was heading to the same place as us was, to my mind at least, a foolish plan. We drove past acres and acres of tea plantation in the flat bottomed valleys. Every inch of the land is seemingly given over to farming, with agricultural terraces tumbling down the hills like a patchwork quilt of every shade of green imaginable.

Eventually we hit Kigali, driving past the taxi park and heading up the hill. The striking thing about Kigali is how well looked after it is - it's clean, there's no rubbish, the roads are paved, it's organised and the traffic's not mental. The perfect city antidote to Kampala in fact. It unsurprisingly transpired that Dan didn't know Kigali at all, and we didn't have a map. So we were driving randomly around hoping to spot a landmark that looked familiar to Elizabeth, who had lived there in a former life. We eventually made it to the Hotel Chez Lando a mere 14 hours after we had left Kampala, and I was wishing we'd climbed aboard a plane and arrived 15 minutes before we'd set off. Elizabeth headed out for a business dinner and Adam and I amused ourselves trying to translate the French menu, with no success, only to find the English version at the bottom of the page.

Elizabeth spent the next day in meetings, and Adam and I decided to see the sights of Kigali. Brandishing our faithful, if not trustworthy Lonely Planet and a map from the local rag which had the landmarks in all the wrong places, we got into Dan's van. We'd furnished him with a wishlist of places we hoped to go. We were not expecting much, as on getting to the carpark, we found Dan awaking from his slumber in the back of the van where he had spent the night. Give him his due, he'd done his homework and had developed a remarkable knowledge of the city's geography.

We arrived at the Kigali Memorial Centre, to be greeted by a firmly shut iron gate and a guard making X-factor signs at us, demonstrating that the centre was closed, rather than displaying his affection for Simon Cowell. We were informed that it would be open the next day, since Easter Saturday generally isn't a public holiday. We decided to visit a couple of churches outside of Kigali, 25 and 30 km south of the city. En route we stopped at a memorial garden, where the grass was being cut by people brandishing machetes, which had an uncanny irony to it. The remains of over 600 genocide victims were buried here, some identified by their first names only, and some simply identified as 'boy'.

Along the roadside, heading out of town were bands of men working on roads or in gardens or on construction sites wearing pink tabards. These uniforms identify them as prisoners suspected of having been involved in genocide on some level - most of whom killed or looted - awaiting trial. They work on civic projects, a useful form of community service. The prisons are overrun with genocide suspects with little hope of a trial in the near future.

We arrived at Ntarama Church in a downpour. Around 5000 people were killed here by Interahamwe militia using grenades and machetes. Most people were sheltering in the church itself when the grenades were thrown in. The church is a humble brick building with rows and rows of simple benches. At one end of the church are shelves containing the skulls and femurs of the dead, many showing evidence of how brutally they were massacred, clean lines sliced through the bone by the soldiers blades. Around the church, hanging on the walls are the victims' clothes, cooking utensils and whatever possessions people brought from home in the few days they took refuge before a neighbour told soldiers of their whereabouts. Outside you could see where the grenades had entered the building, blasting through walls that are 18 inches thick. The steel window frames were twisted and bent where the people trapped in side had tried desperately to escape. The place felt desolate and abandoned. It didn't feel like a church. It was deathly quiet.

We got into the car, feeling sombre. We drove another 5km to the next church at Nyamata. We met Steven, now 24, at the entrance, who was 8 when the killings started. Above the entrance to the church, there is a banner which reads,

"Iyo uza kwimenya nanje ukamenya ntuba waranyishe"

I asked Steven what this meant. He said that it was far more philosophical than the translation

"If you had known me, and if you had known yourself, you would not have killed me"

While waiting to be shown around inside the church, Steven told us his story. They heard the soldiers coming, they were beating drums as they advanced towards the village. Steven fled the village with friends and neighbours. His Mother and Father, Uncles, Grandmother and brothers remained behind. After the genocide was over, Steven was adopted by one of the adults that he had fled with. This man spent 4 years trying to trace survivors from Steven's family. He eventually managed to track down his grandmother, and Steven and his sister were reunited with her. The rest of his family had been slaughtered. The man who had killed his father and 2 uncles turned up at Steven's house in 2003 begging for forgiveness. Steven told us that his grandmother refused to let him in the house. His sister couldn't speak to him. Steven went outside and asked him to leave, and if he felt the same way in a week to come back and ask again, this time bringing details of where the remains of his family were buried. The man returned the following Sunday. He took them to a pentecostal church. During the service, there was a period for free speech, where people took to the altar and spoke to the congregation. The man stood on the altar and asked the deputy pastor and a number of others in the congregation, men and women, to stand. He identified these people as being complicit in the hiding of 32 bodies in a disused latrine. 9 years later, the bodies were still there. Those involved were arrested. The man, along with Steven and others, removed the bodies from the latrine. Steven told us that they were in varying states of decay, the ones in the middle still had flesh and skin. They brought the bodies to Nyamata to rest. Steven told us that he has forgiven the man who killed his family. They drink beers together these days. He's a stronger person than I think I could ever be.

He took us into the church, much bigger than Ntarama. It seemed a lot more peaceful, but I think that was the light. There were piles of clothes on every single pew and the altar. The altar and font were pockmarked with bullet holes, and light peeked in through tiny shrapnel holes in the tin roof, created by grenade explosions. There was an eerie sense of oppression. 10000 lives extinguished. We were told that the Hutu soldiers tied people to the pillars and amputated their limbs one by one, often hours apart. They used the dismembered arms to wave at other Tutsis imprisoned in the church as a warning of what was about to happen to them. Those who had money, paid the soldiers to shoot them dead, to avoid suffering. We went down into the basement of the church where there was a coffin and hundreds of skulls. He told us that in the coffin were the remains of a mother and her baby. Hutu soldiers had sharpened two wooden poles and driven one through the woman's chest and through the baby that was strapped to her back, and a second pole through her abdomen and out through the back of her neck. They were buried as they were found. Out the back of the church were two large tombs. Inside the tombs were stacked coffinsm 5 or 6 high, each containing 35-40 skulls. It is estimated that the remains of 40,000 people are buried at the church.

Returning back to the church entrance we met Charles. He was also 8 when the genocide happened. He was in the church when the Interahamwe arrived, along with his brothers and sister. Charles, one of his brothers and his sister were still alive after the first wave of mass execution at the church. His brother knew that the soldiers were coming back. He Charles that he needed to hide and pretend he was dead. He covered him in blood, told him to lie with his head inside a small hole in the bottom of one of the walls - we were standing next to where Charles had lain while he was recounting his experience - and then piled dead bodies on top of him. His brother told him he was going to check on the rest of his family, but that he would be back. He never came. The soldiers returned to the church and executed more people. When it was quiet and they had gone, Charles came out of his hole. His brother was dead, his sister seriously injured. She asked him to find water. He brought some to her, but while he was fetching it he heard the soldiers returning a third time. He went back to his hiding place. The soldiers moved amongst the bodies, jabbing at them with spears to see whether there were any survivors. One of them put a spear in Charles' leg. There was a pile of bodies between him and the rest of the military. Charles looked him in the face. The soldier asked him if he was still alive. Charles answered 'Yes, please forgive me'. The soldier told him that he didn't want to kill him, and sparing him, went to join the rest of his group. There were 7 survivors from the church. They fled and hid in a nearby swamp. Soldiers came to the swamp looking for survivors. 2 of the 7 died from hunger. It was harrowing to hear his story first hand.

We left the church and headed to Hotel Milles Collines - better known as Hotel Rwanda. If you hadn't read about it, or seen the film, you wouldn't know what had happened there in 1994, it feels like any other business hotel. But it seemed like a fitting place to have a drink and take stock of the places we had been and the stories we had been told. The rest of our day was spend mooching around, most places of interest being closed due to the public holiday.

The next morning, we headed back to the memorial, only to discover that it was still closed. I was sorely disappointed to be leaving Kigali without getting to see it, but c'est la vie. We spent the morning at a craft village, piled high with what I now consider to be the generic East African souvenir tat, although I did buy a wooden statue of a pregnant woman that seems to resonate with my purpose here. We then set off on the brief journey back to Uganda and onto Lake Bunyonyi.

I loved Bunyonyi the first time I went, and I loved being back there. We stayed at Bushara Island camp, a 10 minute motorboat ride from the main land. It's a beautiful, peaceful place with abundant birdlife. We slept in a huge furnished safari tent with views of the lake. We spent two days relaxing, swimming and walking. We spent a merry afternoon attempting to circumnavigate the island in a dug out canoe, failing miserably and wasting a lot of time spinning the canoe around in circles. It was true downtime.

This week was spent doing a variety of things - the usual mixed bag. I had a couple of days on labour ward, we tried to relaunch triage, I did some teaching. Tomorrow I travel to Arua, in the far north-west of the country, 10 miles from the border with the DRC. It will be my last fistula camp during my time here. I'm looking forward to it.

Photos of the trip are here

Fistula Outreach Camps

For the past two weeks I have been away from Kampala, working with some of Mulago's urogynaecology specialists who were conducting VVF outreach camps. The first of these was in a small town called Kiboga, which geographically is not far from Kampala, along a well paved road. In reality, there are many constraints faced by women afflicted with fistula - who will pay for transport and food, who will farm the land, who will care for the children - that prevent them from accessing definitive treatment at Mulago. The second camp was in a larger town called Mityana, along a rougher road but still within reasonable distance of the capital. The camps are endorsed by the Ministry of Health and funded in part by an organisation called AMREF.

We arrived in Kiboga, me, two specialists (Mwanje and Alia) and a scrub nurse (Alice), on a sunny Monday morning. Just before we entered the hospital grounds, Mwanje leaned out of the window to talk to someone coming out of the hospital.

'We're here to do a fistula camp'.
'Oh, er, do you have an anaesthetist with you, because we don't have one'.
'What are you talking about? You ARE an anaesthetist'.

And so we met 'Uncle' the resident anaesthetist, whose excuses as to why we couldn't work were many and varied and would be a constant theme over the next few days. 'We have no instruments', 'We have no linen', 'We have no linen', 'It's too much work', 'I worked all night, we did two sections' and so forth. Fortunately, our humour and patience were as limitless as his excuses and so we did manage to get some work done.

We spent the first afternoon screening patients. Radio announcements are made about the camps in advance. Almost everyone has a small wireless radio, or knows someone who has one, so this is the best way of achieving maximal publicity. Prospective patients turn up on the first day, and the plan for the rest of the week is made from there. We saw around 20 patients and operated on 13. While the majority of women attending do have a fistula, we also saw women with prolapse, stress incontinence and pelvic infection. One patient had lived with a vesico-vaginal fistula (communication between the bladder and vagina) for 24 years. It proved impossible to get theatre space the first day, Uncle was dodging us, there was an emergency case and then it was too late in the day to start.

On Tuesday and Wednesday, we managed to get through our 13 patients. We acquired a second theatre table, and after cleaning and oiling the table and topping up the hydraulic fluid it was semi-functional, despite one episode when the head of the table collapsed while the patient was being prepared for spinal anaesthesia - fortunately without the needle in her back, and with the gas man to catch her.

There were several very complex fistula cases which were repaired, third degree tears that had not been repaired which we operated on, ureteric implantations performed and an exploratory laparotomy and adhesiolysis. There was one emergency section performed while we were in theatre, resulting in a neonatal death due to severe hypoxia. I spent 45 minutes ventilating in vain. There is no special care baby unit in Kiboga, or indeed before Kampala, and so even if resuscitation is successful, there is no facility for supportive care. The hospital itself is a decent building, but it's not being used optimally. There was no running water during our stay and very few staff - 3 doctors in total. It was, however, fairly clean, all things considered.

At the end of Wednesday afternoon, our work in Kiboga was complete, and no new patients had attended, so we returned to Kampala with the aim of spending two days operating there, if we could get an anaesthetist to work with us. Unfortunately there was no-one available, and in fact there was no-one for the elective list in the fistula theatre that would normally be running until 3 in the afternoon. We repaired a fistula in a 4 year old who had fallen onto a tree branch some time back. The cause of the fistula was confirmed by the discovery and removal of two pieces of wood lodged within the tissue, one around 2cm long and the other about half a centimetre. We went from here down to the main gynae theatre to perform a bilateral ureteric re-implantation and bladder repair on a woman who had had a section 2 days previously and who had not passed urine since. It was a complete mess, but surgery was successful. Friday was a day of running around organising and doing admin.

I worked the night shift on labour ward on Saturday, spending the night in theatre, getting through 8 sections. The SHO on the shop floor managed to do 3 more sections in gynae theatre. The cases were varied. A woman had pushed for 12 hours before being referred from a clinic to the hospital with a stillborn baby and a difficult section due to severe impaction of the head in the pelvis. Three women had uterine scar dehiscence and all of their babies survived, simply due to us luckily eing able to move them through theatre fairly quickly and avoiding complete rupture. One woman had an undiagnosed placenta praevia. At 4am we ran out of fluids, had no catheters, no venflons and there was only AB +ve blood in the hospital. We had to stop theatre with 3 sections still pending. In that time we had a cervical tear which I repaired on the ward with no light and no sponge holders, kneeling on the floor. We had a number of severely anaemic women, and I spent a merry hour running around the various wards trying to find fluids and gear, with minimal success. All things considered, it was a fairly successful night shift. Sunday, naturally, was a write off.

The following morning, myself, Barageine and Sister Rose piled into another pick-up to venture to Mityana for the week. After a protracted departure, involving paperwork and diesel fuel, we bumped along the road to the hospital. The hospital is in fact best described as an assortment of shacks in varied states of dilapidation. Cows, dogs and ducks roamed the compound freely, whilst chickens strutted through the wards oblivious to anyone. Bags of blood hung from improvised drip stands made of branches. The theatre was small, filthy and clutteres, plants growing in through the windows and insects populated the inside of the semi functional theatre light. There were no overhead lights, no running water and no proper linen - drapes were made from ripped up scrub shirts. The patients were screened in an office, and listed for theatre. We saw a woman who had a catheter which had been in for over 6 months, having had her fistula operated on in a private clinic and then being discharged without follow-up or instruction, and another woman who was operated on at a previous camp and had gone home with the gauze pack still in-situ 4 months earlier. Many of the fistulas were extensive and complicated.

We worked on 27 women, over 4 days in theatre. At points we would be operating, while another patient has a section in the same theatre on a flat bench with no drapes and in the 'anaesthetic' room a child would be being circumcised or having a dental extraction without anaesthetic. The conditions were shocking. After 4 days of operating in the theatre, I was glad to be leaving, amazed that the staff can work week after week in such conditions, and yet dismayed that no-one pushed for change and improvement. I will be glad to get back to Mulago next week.

I took some photos, I don't think words can do justice to the conditions that patients and staff are existing in. You can find them here and will note the striking difference between the two hospitals.

Planes, Trains, Automobiles, Dhows, Boda Bodas and Tuk Tuks

Things at Mulago calmed down after surviving the week on labour ward. Urogynaecology is refreshingly quiet. The set up is very different. Mondays and Tuesdays are ward round days, and so, since most of the patients are electively admitted and for the most part relatively well, the round is usually finished by 11am. Wednesday and Thursday are theatre days and Friday is clinic. There is a dedicated fistula theatre, with the capacity to run 2 tables at a time. Most procedures are done under spinal anaesthetic. The week I started, there had been no list the previous week, and the specialists were upcountry on an outreach fistula repair camp. This meant that the ward was even quieter than usual, and so I had the opportunity to go to theatre for the family planning list, performing two sterilisations by mini-laparotomy, under local anaesthetic. This was a first for me, since the vast majority of elective female sterilisation is done laparoscopically at home.

Normally, the urogynaeology team perform 6-8 procedures a week, and about half of these will be fistula repairs, and the rest will be prolapse repairs, vaginal hysterectomies and sling procedures or Burch colposuspensions. The majority of fistulas here are obstetric in origin, since prolonged labour is common, and access to definitive care limited. There are also women who attend with pathology due to trauma, secondary to sexual assault, particularly in times of conflict. It is not uncommon to meet women who have been victims of rape at the hands of groups of soldiers.

Fistula is a taboo subject. There is difficulty in setting up functional fistula centres, as the perception is that to do so is to admit that fistula is a problem within the population. Until recent times at Mulago, less than 10 fistula repairs were being performed each year. Now the department repair several hundred annually. Women with vesico-vaginal fistula cannot control the passage of urine. They are constantly wet, which causes all sorts of issues with hygiene and tissue viability. They become social outcasts, marriages are destroyed, they are unable to have intercourse, being considered 'dirty'. In some places, women with fistula are shut up in small huts, like dog kennels, away from the family home, unable to stand up straight, clenching their legs together in an attempt to stay dry. They are not allowed to leave these huts, meals are passed in through small holes. These women develop disfiguring contractures of the limbs, necessitating surgery.

Sadly, this happens all over the developing world. Even sadder, is the fact that while fistula is operable - and when performed by someone with significant experience can be extremely successful, and life transforming - access to such surgery is difficult. Whether this is a question of geography, finance, stigma or a combination of all these factors and more, I don't know. The good news is that the team at Mulago are running fistula camps at hospitals in more rural areas of Uganda, each lasting a week. They are running one every two weeks for the next 6 months. Hopefully taking experienced surgeons into these areas for intensive periods, will help to tackle some of the issues, and ultimately transform the lives of these women.

After two weeks on urogynaecology, I was feeling much happier with being out here. The job seems to swing through extremes of nice highs and horrific lows. The other thing about urogynaecology and the way the job is set up affords me time to work on other things. I had run some really good teaching sessions with the midwives, interactive tutorials where we all learned new things. I also spent some time thinking about how to take some of the projects forward that have stalled or have not worked as well as we would have liked. It's a happy medium for now, but I'm sure that in a couple of weeks I'll be bursting for some more labour ward action.

Last weekend was a long weekend, for International Women's Day, which is a national holiday in Uganda. As a spur of the moment thing, we decided to fly to Nairobi and travel to Mombasa, Kenya. The idea was conceived and flights booked quickly, to depart the following morning. Elizabeth, Adam and I headed bleary eyed, to Entebbe airport at 4am. We arrived in Nairobi around 7.40am and after battling to get through immigration, 'You can't pay with this $100 note, it was printed in 1999', we met Moses, who was our driver for the day. Having agreed our price, we headed to Nairobi railway station, where we bought 4 second class tickets for the night train to Mombasa, for the three of us and our imaginary friend 'Boris'. So far, so good. From here we went to the National Museum, which was fab. It was an eclectic collection of natural history, cultural artifacts and good art. We whiled away 3 happy hours here - stopping for obligatory coffee and cake at the museum cafe. Nairobi has a reputation for being extremely dangerous. We were expecting seedy run down streets, but what we saw and experience couldn't have been further removed. Our experience of Nairobi was one of a cosmopolitan city, a city on the up, and quite different from Kampala. We decided to attempt to get to the giraffe sanctuary, in the northwest part of the city. Moses said he knew where it was. We stopped to get fuel. It seemed to take us an age to get there. And then, on a random road, seemingly in the middle of nowhere, the car cut out. 'They didn't put the fuel in'. And so we found ourselves attempting to push the car along this random road, in the searing heat, the boot so hot you couldn't push for long without burning your hands. Moses spent some time on his cell phone, trying to arrange a rescue plan. We had no water, were ridiculously thirsty and had no sunscreen on. We decided to walk to the nearest watering hole, which thankfully wasn't far. We thought we might get some lunch there while waiting for Moses to sort out the transport situation. 'We have chicken, goat or beef'. 'OK, how long will it take?'. 'Probably about 40 minutes'. So we were stuck in a local bar, with no immediate chances of escape, with a train to catch, a broken car, somewhere on the outskirts of Nairobi. But the beer was cold.

About 30 minutes later, Moses rocked up in the car, engine running, and we decided to cut our losses and get back to the area near the station, so that if the car died again, we'd still catch the train. The giraffes would have to wait. The restaurant we chose to eat in was closed. By now it was late afternoon, we were hungry and becoming grumpy. We took our chances on a restaurant called Berber's. It became clear that this wasn't a restaurant travellers stumbled upon very often, apparently it was 'an honour' for us to be there. And we would have felt honoured to be there if the food hadn't been so terrible. But it was all part and parcel of the experience and we were just glad that we weren't still pushing a car along the road in 30 degree heat. After 15 minutes of panicking, trying to get hold of Moses on the phone - who was driving around Nairobi with all our stuff in his car while we ate at the restaurant - who had gone AWOL, thinking that all our worldly possessions had been pilfered, we located him, got back in the car and went to the station.

Nairobi railway station was like something out of a black and white film, except the steam trains of yesteryear had been replaced with spluttering, wheezing diesel engines. We waited on the platform, people watching, until the train drew into the station an hour before scheduled departure. We located our cabin, threw our stuff in and made ourselves at home. We were pleased to have somewhere to lay our heads, and pleased that we had survived the day. The train pulled away from the station bang on time, and we cracked open some Tuskers and watched the outskirts of the city speeding past the window as the sun began to set. The train manager paid us a visit to welcome us on board, informing us about meals and arrival times, and to check we were happy. Good old British Rail could learn a thing or two! The bell rang for dinner and we headed to the dining car where we had stew and rice, washed down with some red wine.

There's something very soporific about the sounds and motion of a train. Leaning out of the window, string at the stars and watching the lightning cracking across the horizon, I felt overwhelmingly content. Around 10pm I clambered up into my bunk, and fell asleep to the clickety clack of the train thundering through the Kenyan countryside.

The bell for breakfast at 6.45 was a rude awakening. We stumbled through the train for a serving of fry-up, and a much needed cup of coffee. At 9.30, right on schedule, we arrived in a very hot and very humid Mombasa. We took a tuk-tuk to the hotel, checking in early for much needed showers and then headed to a beach just outside of town for an afternoon of kicking back in the shade a palm trees, looking out across the white sand at the azure and topaz sea. It reminded me of Zanzibar although the colours were different. Elizabeth took a camel ride, on a majestic beast called Charlie Brown. Adam and I plodded through our books, keen to avoid becoming sunburned. We headed back after a few hours, changing for dinner. We were picked up from the hotel and transferred to the other side of the bay, to the Tamarind Dhow, a traditional Mombasan boat, for a dinner cruise. We ate lobster, while drinking nice wine and listening to the sounds of the band, knocking popular classics with an African twist. There's nothing like eating a good meal with friends, in the open air, floating past the world. It was fab.

The following morning we walked to the Old Town, exploring Fort Jesus, a semi-derelict Portuguese fort, unfortunately badly maintained. We then meandered through Old Town's streets. Since it was Sunday, most things were closed, but it had a lovely feel to it, similar to Stone Town, but not quite as nice. After a leisurely lunch back at the Tamarind - this time on land - it was time to head back to the station. The train back, this time with an imaginary child called 'Prunella' sharing our cabin, who was in absentia due to 'sickness' necessitating an imaginary hospital admission, was just as much fun as the first time. A little drunker and a bit more balmy, dinner was spent being childish and messing around, pretending to be 'Cousin it', for reasons I can't remember. After another sound night's slumber in the sleeper car, we spotted zebra and giraffes from the window of the train. Having not yet seen zebra in the wild, I was over the moon!

We arrived later than expected in Nairobi. We were collected by a different driver, Steve. We visited an art centre, and this time actually made it to the giraffe sanctuary, where we got up close and personal with Laura, a female giraffe. Kissing a giraffe is one of those life experiences that I will always remember, but have no desire to repeat! After a bit more craft shopping we went back to the museum so that Elizabeth could buy a painting she had fallen in love with at the beginning of the trip.

We had a few hours to kill - or so we thought - and after consulting the driver about how much time it would take us to get to the airport, we went to do a spot of shopping. All was well until Steve went missing in the car park, with a mobile phone that didn't work. And so for the second time on the trip we began to panic, knowing we had a plane to catch. We eventually found him, by now all of us a bit agitated. But we were reassured that it was only going to take around 40 minutes to get to the airport. 3 hours later, with 50 minutes to the departure of our flight, we were still stuck in a traffic jam, with what seemed like the rest of the population of Nairobi. Adam got out of the car to try and find out if we could get motorbikes to the airport - 'They are banned in the city centre'. The crowning moment in that increasingly tense journey was when Steve read the number of the radio station as the time, rather than the clock, and then suggested we could 'just get the next flight'. When we explained the cost implication of 'just catching the next flight' I think it dawned on him that we really did need to get to the airport. Creeping out of the congestion, Steve floored the car, in one of the most dangerous journeys I have ever been on. Elizabeth's suggestion of 'At least if we crash, at this speed we'll be killed outright' did nothing to reassure me. We arrived at the airport 29 minutes before take off, to be told that we could probably check in, but at that point there were not enough seats on the plane. The next anxious 10 minutes were spent standing at the check in desk, drawing effigies of the driver on the back of a departure card. Bob, the desk steward then announced that there were seats, and so we tore through the airport, skipping and dodging other passengers to the gate, where we were escorted onto the plane, people staring at us for being 'the ones that held the flight up'. I have never been so glad to put on my seat belt and be subjected to the safety talk. The weekend had been fantastic, but in a way, I was glad to be heading back to Kampala.

Photos can be seen here

Hard Labour

Mum and I had a few days together in Kampala. She wanted to go and visit the hospital, so we went. I showed her around the midwifery led unit, ward 14 first. A woman had just given birth in the corridor, but the ward was otherwise fairly quiet. Still she was a little shocked at what she saw. We then went to the main labour ward, chaotic and overrun as usual, women in various stages of labour strewn about the place, on mats on the floor, some in beds, some on benches. I don't think she really knew what to make of it, and I don't think it reassured her about the decision I had made to come here. But I think that when I return in August, with tales to tell, she will at least understand them better than most people, for having witnessed the hospital first hand. Our time in Kampala was otherwise spent with friends, barbecuing, eating and drinking good food and wine and doing very little else. We spent an afternoon exploring Owino market and the new bus park, but after the time we spent on the road, we were both tired, and fed up of being 'tourists'. And so much of the day was spent hanging out in the garden being tormented by the dog, and chatting with Doris, our housekeeper, who took a special shine to Mum, probably because they both had motherhood in common. She left in the early hours of Saturday, and I felt a little bit empty after her departure, having been constant companions for 3 weeks.

We had decided as a house, that since most of the 'original' housemates had left, it was time to upgrade the chipped and cracked plates, bent cutlery and plastic tumblers with stuff to make the house more homely. We also decided it was time to upgrade the cleaning stuff for the house too, much to Doris's delight. She admitted to us that nothing had been replaced in the 6 years she has worked at the house. Doris is much happier and upbeat, with a new enthusiasm for her work. And we felt good for doing something seemingly small and routine, that it some way showed that we value Doris and her work. So, we're a happy house! Of course, on our spending spree it was also deemed necessary to buy some 'fun' house stuff. We returned from our shopping spree laden with a volleyball, basketball, 4 badminton racquets and shuttles and a universal net. Ravi and Adam spent a bit of time putting the net up, and the following afternoon, the Inaugural Naguru Lawn Sports Society Meeting was held. Of course, no sports day is complete without a bit of beer and a barbecue, and it seems that our weekends have taken on a whole new meaning.

My first proper week back at work was taken up with meetings, teaching and administrative tasks. I spent time making edits to some of the documents I produced prior to going on holiday. I walked around the department, to see what was happening in the various different areas, saying hello to people and conscious that I hadn't been visibly present there for a number of weeks. I decided to follow-up on some of the things we put in place right before I went off travelling - I had put whiteboards up, providing pens and a small amount of money for replacement pens, and had given brief instructions on their use. It was a small experiment on my part, as I was curious to know whether even something as simple as replacing a sheet of paper with a board to write the theatre list on, giving a static point that would help improve prioritisation, would be implemented without me having to push it. Similarly, having given a tutorial on the whiteboard on 14 as a tool and having seen the initial enthusiasm of the staff, I had been hopeful that they would get it off the ground off their own backs. I was dismayed to see that the examples I had used to demonstrate how to fill the board in, were still there, and it was clear to me that the boards hadn't been touched. But I wasn't really surprised, and a little redeemed from my own cynicism. It led me once more, to question the sustainability of the work I have done here so far. And I now need to think about maybe taking a different approach to the projects I have been trying to get going. We have had a change of guard, so to speak, with staff - particularly effective senior midwives - being rotated. This will hopefully bring an injection of renewed enthusiasm to many of the clinical areas which will hopefully translate into improvements in patient care.

The weekend came round quickly, good old St Valentines day looming, Avner and Ravi were both out of town and myself, Adam and Elizabeth needed some down time together to catch up on each others' lives. We decided to treat ourselves and spend some time at a hotel on Lake Victoria's shores, taking advantage of their weekend Valentines special offer that sounded too good to be true... and was. We arrived to discover that it wasn't as cheap as the flier had suggested. But it was a bloody nice place, so we decided to stay anyway. We persuaded them to put an extra bed in our twin room, and managed to obtain a corporate rate for it too. We then settled into the terrace bar and had a long deep and meaningful while gazing out at Lake Victoria as the sun set. We spent the night under duvets in our air conditioned room - extremely decadent and a real treat by our standards!

Saturday was a pool day, catching rays, reading and messing about in the water. It felt a million miles away from Kampala, a holiday to recover from my recent holiday. Avner and Ravi's plans for the weekend had changed, and we persuaded them to come and join us. Av arrived first with supplies for Bloody Marys, took a shower and shaved his face, leaving a moustache that wouldn't have been out of place in a top shelf movie, and proceeded to prance around in a towel for a bit. We then went for dinner - Av had dressed by now, thanks goodness - and Ravi came from the airport to meet us shortly after we finished eating.

We had to walk past the pool to get back to the room, where there would now be 5 of us staying in 3 beds. It seemed only natural to swim, in the dark. I dived in in my dress - I suspect that a full day of imbibing alcohol may have been responsible for my behaviour - swiftly followed by the rest of the gang, wearing various amounts of inappropriate swimming attire. It was fun, childish, but fun. We went back to the room, threw some drinks together and chilled on the balcony into the small hours. Sunday, we travelled back to Kampala, feeling relaxed and refreshed, and not too hungover, all things considered.

Back at work, I was still feeling a little bit out of the swing of things, and the familiar feeling of dread and paralysis that affected me when I first arrived was washing over me again, less intense, but still palpable. I realised that I needed to face it head on, and really throw myself back in. And so began my week on labour ward, which was to be challenging and at times surreal. Throughout my time here so far, I have tried to write the blog as diplomatically as possible. I apologise if this is not the case with this posting.

I spent the Monday in theatre, tackling the emergency section list. We had a woman with a bad uterine rupture that had gone right through the back of the bladder. I managed to repair the uterus, but struggled to deal with the damage to the bladder and called the specialist in, who in turn called in the urogynaecologist. Uterine ruptures are common here, some much worse than others, but I am still not at the point where I am confident enough to 'just get on with it', as I don't feel that I have the experience of repairing a uterine rupture, or performing caesarean hysterectomy to do it independently and safely. This is considered an alien concept by some of my colleagues here, having been indoctrinated in a different system, but I can't subscribe to the 'see one, do one, teach one' philosophy. While I came to Uganda to gain experience of these types of things, I refuse to approach my patients any differently to what would be expected of me in the UK. It might hold me back a little, but I can sleep at night.

On Tuesday, I met with the head of department and two of the specialists to work through the applications for the exchange programme that runs between Mulago and Liverpool Women's. We spent several hours poring over the applications and discussing them. We selected two midwives to go. I returned to labour ward around 1pm, and was told that there was a destructive delivery happening. I have seen one before, quite early on in this job, and while they are brutal and unpleasant, they still have their place, especially in this setting. It was thought the the baby was in a face presentation, badly impacted and no longer alive. In this situation sometimes a destructive delivery and achieving a vaginal delivery rather than performing a caesarean delivery is a safer option for the woman, if not an especially pleasant one. The specialist was struggling to come to a decision about how to proceed, the landmarks being difficult to determine. The patient was pushing well. An episiotomy was performed. At this point it was noted that the breech (bum) was presenting. A breech extraction was performed, legs then trunk then arms. The head was stuck. Fast. What happened next will stay with me for the rest of my life. as the specialist tried to deliver the rest of the baby the head separated from the body. We had to take the patient to theatre to deliver the baby's head by caesarean section, the thing we had been trying to avoid in the first place. It was one of the most traumatic things I have ever experienced. The rest of the week on labour ward was busy, the usual mixed bag of eclampsia, massive bleeds from undiagnosed major placenta praevias, uterine ruptures, hysterectomies, severe malaria, severely hypoxic babies and so forth. Everything else that happened that week was eclipsed by Tuesday's horrific experience. But I managed to complete the week on labour ward, and I was proud of myself for managing to do that, but also astounded with myself for being able to compartmentalise my experience in order to function.

The Friday of that week, Ravi left us, his 6 week placement at Mulago finished, ready to go back to the States, graduate from medical school and take up his residency post. We had a big barbecue send off, which was a welcome antidote after the week's events. And we packed him off in a taxi a 3 in the morning, bound for Entebbe airport. One of the nicest people I have ever met, and someone I feel privileged to have spent time with, I know he will be a superb doctor, and I wish him well.

Sunday evening, walking away from the labour ward felt like a release from incarceration. I'm pleased to have finished there for a few weeks, but glad that I'm back in the swing of things once more. I am reminded, once again of how lucky we are to have the NHS, how lucky we are to be born where we are born, and how that affects our destiny. I also think this is the first time I've looked forward to doing a block of urogynaecology too!

January...Part 4 - Hippos and dirtroads and birds, oh my!

The morning after we had been tracking the gorillas, the world started falling out of my bottom. So it was a good thing that we hadn’t planned on doing anything for the day, as I quite literally couldn’t have left the lodge. We spent the day watching the birds in the valley – sunbirds, sparrows and the like – brightly coloured on a backdrop of blue sky. After lunch we decided to try and get an idea of the size of our hotel bill, and it was at that point the lodge manager announced that it wasn’t possible to pay by credit card, despite being reassured by the office in Kampala that we would be able to. We had a minor panic at this point, having literally just enough cash to cover the bill with none left over for emergencies. We spent around an hour unsuccessfully trying to work out a solution. The nearest ATM was more than an hour’s drive away. We called Eddie, who had disappeared up a mountain somewhere, to take us to the ATM. When he arrived an hour later, he reminded us that it was a public holiday, and should the ATM be empty, we were stuck. We decided it was probably most sensible to take our chances with no rainy day fund to speak of. It was a day of doing absolutely nothing, that turned out to be fairly stressful. All in all, the ‘splurge’ turned out to be a true disappointment.

The next morning, we left at around 8, driving to the next decent sized town, where the cash machine decided that it initially wasn’t going to dispense any money for us, and then 5 minutes later after having no success inside the bank, decided that actually it would give us some funds after all. We were relieved. We then set off for Ishasha. Arriving at around 10, we hoped to catch a glimpse of the tree-climbing lions. As it turned out, the lions were not feeling particularly tourist friendly and had abandoned the branches of their fig trees. We didn’t spot a single one. Disappointed that nature had won the game that day we carried on through the park in the direction of the Kichembwa Lodge, which was to be home for two nights.

Queen Elizabeth National Park is very different to Murchison Falls. The hot, dry savannah continues as far as the eye can see, with bits of scrub here and there, and the occasional damaged tree, providing evidence of the presence of elephants. We saw hundreds of Ugandan kob, a sort of antelope, and numerous elephants on the horizon as we drove along the dusty dirt track, baking in the blistering sun. The lack of game meant that the drive was fairly dull, with little to grab our attention or capture the imagination. As we got out of the park and onto slightly better roads, Eddie picked up the pace. Along the way were brightly coloured butterflies. Wherever there was a puddle, the butterflies congregated and as we drove past, they fluttered up from the ground like handfuls of wedding confetti, streaming out from underneath the back of the car. Beautiful. We arrived at the lodge, which was a series of round thatch-roofed huts, reminiscent of Hobbiton. We got to our hut and were greeted by a breathtaking view of the plains below, reaching what seemed to be the edge of the world. It was a really special place. We reflected on the day’s game drive and the arid landscape that we had seen, and decided to change our plans. We’d originally decided not to go up to Murchison Falls, but Mum wanted to see giraffes, and we figured that we would probably have more luck seeing big game up at Murchison. We decided to spend one night at the lodge, game drive the next morning, head to Fort Portal for 2 nights and then spend 2 nights at Murchison.

Our game drive the next morning was again, fairly fruitless, save for watching male kob sparring with each other at dawn, and group of mongooses/mongeese/mongice/mongoose (exactly what is the plural of mongoose?!). There was a disappointing lack of most of the big 5. We were out in the park before the sun came up, but as it rose it was seemingly too hot and dry for the animals. I was glad that we had changed our plans. After eating a breakfast of fruit, bread and eggs while gazing at some salt flats, we began our journey to Fort Portal, and I started a series of phone calls to rearrange our accommodation. Unfortunately the guest house we had already made a reservation at was unable to accommodate us a night earlier, and so referencing our ‘trusty’ lonely planet, settled for a place called the Y.E.S. Hostel. We drove round some of the crater lakes which sit outside Fort Portal proper. on the way there We saw endless numbers of men pushing bikes impossibly laden with bunches of green matoke, up dirt tracks in the midday sun, and women and children tilling and farming the land. We were in very fertile country, on account of previous volcanic activity in the area. The fields were full of coffee, tea, matoke, papyrus and other crops.

We stopped for lunch where we got rid of the packaging from breakfast. My Swiss Army knife was wrapped up with them, and was inadvertently disposed of, without either of us realising until the next day and by which time it was too late. From here we continued to the sparse, prison like hostel. We were the only guests. Mum was incensed, ‘I stayed in a place like this in Afghanistan in the ‘70s, and there was shit up the toilet walls there too’, I suggested that our options were limited but we could check out the posher – and even more soulless – hotel just up the road. On balance, we decided to stay put and grit our teeth for 3 dollars a night. On walking to the posher hotel we became surrogate parents of a random dog, who followed us all the way there, entered the ground with us and sat next to us while we drank cold beers in the shade. The dog found the rest of the customers fascinating and whiled away a few hours making a nuisance of itself. At one point the bar manager came and asked us if the dog was ours, and we quickly denied having any connection with it. As we left, the dog decided it had probably best go home and followed us back to where we had found it. We had concluded quite quickly that Fort Portal itself was a place to pass through and use as a base for exploring the area, rather than a place to have a holiday.

We went back to prisoner cell block H, spending a bit of time playing table tennis, without actually using the table at all. In a desperate attempt to make our evening into something we went to a nearby guest house with a roof bar, containing a pool table, a couple of TVs showing football and a noisy parrot. One beer and we decided the best thing we could do was go back to our room and try and get our heads down. This was delayed by Mum's discovery of the lonely hearts page in The Red Pepper, Uganda's quality rag. 'Married man seeks woman for fun times' and ' Man seeks woman from North for marriage, must have untilled land upcountry'.

The following morning, we couldn’t have escaped faster than we did and checked in to Rwenzori View, which was lovely. We headed off to Amabere Cave, just outside of Fort Portal. We met Robert who was to be our guide for the morning, and set off, first on a ridiculously steep hike through burned fields to a vista point from which we could see three crater lakes. He pointed out birds and plants on the way and we had some interesting discussions about religion and politics. Like most Ugandans I have met, Robert talked around the subject matter, including the Anti-Homosexuality Bill of 2009, without actually giving us his personal opinion on any of it. On the way back down towards the falls themselves we met a couple of girls, who can't have been any older than 10, one carrying a bunch of matoke and the other carrying a pumpkin and a machete. Child labour is all too evident outside of Kampala, where less than 60% of kids attend school. We headed to the cave from here, fighting through sinewy forest to reach it. Here, stalactites and stalagmites continue to form, supplied with minerals by the milky coloured water dripping from the cave roof. Robert regaled us with the legend of the cave - full name Amabere ge Nyinamwiru, meaning Breasts of Nyinamwiru. Nyinamweru was the King's daughter, the most beautiful woman in the land, constantly plagued by budding suitors - a feeling I know only too well ;). The king had heard prophesy that he would be killed by his Grandson. The King had no grandson, but the attention of suitors towards his daughter now worried him. In an effort to reduce her beauty and hence the attention of menfolk, the king chopped off her breasts - and in Robert's version of the tale, poked out one of her eyes too - to reduce the chances of her becoming pregnant. This still had no effect on her charms, and so the King threw her into a tower - Robert's version - or into the caves - Bradt Guide version. Either way, she was impregnated and gave birth to a son. In Robert's version, word reaches the King that Nyinamwiru has produced a son, and the King takes the child and throws him into the cave, where he manages to survive by drinking the milky water running from the cave, grows up, learns of the events surrounding his birth and abandonment, meets the King out on a hunting trip and avenges his misfortune by killing him. The guidebook version is not so elaborate, basically stating that the child and his mother took shelter in the caves, and she, having no breasts, replaced the milk with the water dripping from the caves. I know which version I like better. We spent a happy hour scrambling round the caves and behind the waterfall there, and on the way back to the car, Robert pointed out a bald cow, born with no hair, which has to be one of the strangest freaks of nature I've ever seen.

Adam, my housemate, met us in Fort Portal that afternoon, and we went back to the guesthouse to shoot the breeze on the porch with a few beers. We met a Dutch surgeon and his wife, who had trained one of the guys I work with at Mulago, and it was interesting to talk about the differences between Mulago and Kisoro hospitals. We shared a communal dinner around a large family table at the guesthouse, with about 15 other people.

The following morning, we embarked on the long drive from Fort Portal to Murchison Falls. The day was scorching hot and the roads incredibly dusty. We sped along the dirt roads, kicking up the dust that flew through the car and covered us in a thin film of orange particles. I looked like a Scouser with a bad St Tropez tan. As we drove along, the scenery was similar the whole stretch, fields of Matoke, coffee and tea plantations, papyrus springing up from the marshes. Most of the vegetation was also covered in orange dust. Each village we hit was a collection of similar looking huts and shops, some painted with the colours of mobile phone companies, others displaying signs such as 'God is Able Grinders', 'Second Chance Salon', 'The Breath of God Ministries', 'God is Good Barbers' and so on. We saw a man wobble along the road on his bike, so drunk that when he eventually fell sideways into the ditch, he just went to sleep there. There was a brief moment of excitement when a wasp entered the car and Mum nearly had a fit of hysteria, demonstrating the 'Dinsley Wasp Dance' to Eddie and Adam with a modicum of style and finesse. After 8 hours on the road we stopped in Masindi for lunch. They had nothing on the menu we asked for 'It is finished', 'It is over', 'We don't have', so we settled for Chapatti and avocado salad. We were caked in orange dirt and must have looked stunning.

Eddie bundled us back in the car, and drove into Murchison Falls National Park. The scrub had been destroyed by wild fires, sparked by poachers or carelessness. Much of the vegetation along the main road in was blackened, the trees stripped of leaves, their bark scorched, looking eerie in the smoky air. We couldn't get a space at the backpackers campsite and had booked a banda in a lodge. It was more gross than the hostel in Fort Portal and at least 20 times the price. We decided to upgrade to a cottage, which wasn't much better but at least had a shower in it with hot running water. It had been a long and tiring day, and having to spend much more money to get a decent bed made me grumpy for the first time on the trip. We did get a good night's sleep, but I reflected on how the best places we had stayed had been some of the cheaper places.

Eddie collected us at around 6.30 ready to pick Adam up from his campsite and catch the Paraa ferry across into the park proper. The sun was rising over the misty Nile, hippos wallowing in the water like giant rocks with ears. On the other side, we didn't have to drive for long before finding an abundance of giraffes, buffaloes, kob, hartebeest, oribi, warthogs, baboons and hippos. Eddie managed to spot a shoebill stork on the far side of the river, one of the rarer birds here, with a face that looks literally like someone stuck a clog on the front of it. We went to the hippo mating ground, and if hippo foreplay is anything to judge by, all I can say is that I'm glad I'm not a hippo. We saw a solitary lion and a few elephants too. On the way back to the ferry, Adam spotted an upturned, decomposing hippo, a fair distance from the water. Not something the UWA mentioned we were likely to see in the brochure. Quite how it ended up on it's back, all four legs up in the air is beyond me. Perhaps it fell out of a tree.

We spent lunchtime at the Red Chilli Hideaway, kicking back with our books. The tranquility was only disturbed by an octogenerian canadian man using a chair to fend off a warthog that was just standing on the opposite side of a ditch minding its own business. His shouts of 'You might just get more than you bargained for, sonny!' while thrusting the chair towards the hairy pig had us sniggering into our plates, and when he turned to address the rest of his group after the warthog got bored and walked off, with the line 'You just need to make a threatening gesture', I had to leave the table for fear I might embarass myself. After lunch we took a boat trip to the bottom of the falls, watching the hippos pop up from underneath the water with a look of surprise that seemed to say 'Oh 'ello!', and spotting all sorts of colourful birds. There were many more elephants around compared to the last time I was here. It was a really lovely afternoon. We got back to the banda, and helped Adam to pitch his tent outside. We headed over for dinner, and despite us all having headtorches on, Adam still managed to trip over a sleeping warthog. I'm not sure which of them was more surprised.

The next morning we took a hike to the top of the falls, the last leg of our adventure before heading back to Kampala, and again were blown away by the sheer power of the water. We got back to Kampala mid afternoon, and after showering, throwing the dirty washing in the laundry and finally properly unpacking, caught up with the gang. It had been an amazing journey.

Photos can be seen here